Body Adonis Fitness Management

"Our drive leads to lasting results."

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Video Personal Training Web-Form

VPT form is a body composition, health questionnaire, and a liability wavier.

Medial Background Information

First Name: *

Last Name: *

Email: *

Phone Number: *

Date of Birth: *

Do you have high blood pressure?: *

yes

Do you have heart problems?: *

Yes

Are their any history of heart disease in your family?: *

yes

Have you ever experienced a heart patpitation/irregular heartbeat?: *

yes

Have you ever had chest pain?: *

yes

Have you ever experiance dizziness or fainting spells: *

yes

Have you ever had problems with breathing or been diagnosed with as asthma?: *

yes

Do you have allergies of hay fever?: *

yes

Do you get short of breath with mild exertion?: *

yes

Do you have epilepsy?: *

yes

Are you diabetic or have family history of diabetes?: *

yes

Do you expeirance any neck pain?: *

yes

Have you ever suffered a joint injury?: *

yes

Do you suffer from athritis, bursitis, tendonitis, or carpal tunnel syndrome?: *

yes

Have you ever had a hernia?: *

yes

Do you have high cholesterol?: *

yes

Do you smoke cigarettes?: *

yes

Are you a ex-smoker?: *

yes

Do you fast?: *

yes

Are you under a doctors care currently for an illness?: *

yes

Are you on any type of medication?: *

yes

If yes to the last question, then list the medication that you are currently using?:

Are you or were you recently preganant?: *

yes

Poll

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